JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Alunan Avenue, Koronadal City, South Cotabato
Patient’s Name: _Juan Dela Cruz_____________________________________ Age: ______75________Sex:_____Male________
Chief Complaints: DOB, cough Diagnosis: ARF type II secondary to aspiration pneumonia ____________
Date Admitted: _September 23, 2021_______________
ASSESSMENT CUES NEEDS NURSING
DIAGNOSIS
BACKGROUND INFORMATION NURSING
OBJECTIVES
INTERVENTIONS RATIONALE EVALUATION
Subjective:
The patient verbalized
Objective:
P
S
Y
S
I
O
L
O
G
I
C
A
L
&
S
A
F
E
T
Y
N
Acute pain
based on the
pain scale of
the patient
5/10
Acute abdominal pain is a symptom that
can be caused by both minor and major
medical issues and it was noted that
patient was sexually active and is having
multiple sex partner with no protection
used during sexual contact.
Biggers, M.D., MPH. Retrieve February 3,
2022 from:
https://www.healthline.com/health/pain-
in-lower-left-abdomen
Short term goal:
Specific Objectives
1. Assess the
patient on bed
in sem+i-
fowler’s position
to promote
comfort to the
patient’s lower
abdomen.
2. Assess the
patient’s body
temperature
every 4 hours.
Independent:
1. Assist the patient in
demonstrating relaxation
position and diversion
techniques.
2. Assess for the location of the
pain by asking to point to
the site that is
discomforting.
3. Assess the vital signs
maintaining stability.
4. Promote fluid intake
Dependent:
1. Follow the physicians
order of the following
medication/therapeutics:
Ceftriaxone (Keptrix) 1.5g
IVTT q12 hours x 2 doses
Dilute 1 vial to 50cc of triple
distilled water and give via
Solu-set to run for 30mins
1. To provide comfort
and relieve pain by
diverting client from
psychological
responses to pain.
2. Nurse should ask
the following pain
assessment to
determine its
history.
3. Provide the clients
to express it to their
own word to gain
understanding
During the 9 hour
shift, goals were
partially met:
03/02/2021
7:30AM
The patient
verbalized
“Galagnat
giyapn kis-a
pero
naghagan-
hagan na sakit
sang tiyan ko”.
Normal
temperature of
37.1.
7:50AM
Required
medication if
followed by
the physicians
order.
